Nursing Elites

1. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?

• A. You need to try to be realistic. The rape did not just occur.
• B. It will take some time to get over these feelings about your rape.
• C. Tell me more about the incident that causes you to feel like the rape just occurred.
• D. What do you think you can do to alleviate some of your fears about being raped again?

Correct answer: C

Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.

2. When a client with major depressive disorder expresses feelings of worthlessness and hopelessness, what is the nurse's priority intervention?

• A. Encourage the client to engage in recreational activities.
• B. Suggest the client keep a journal of their thoughts and feelings.
• C. Assess the client for suicidal ideation.
• D. Provide the client with positive affirmations.

Correct answer: C

Rationale: The correct answer is to assess the client for suicidal ideation. When a client expresses feelings of worthlessness and hopelessness, it is crucial to evaluate the risk of self-harm. Encouraging recreational activities (choice A) or suggesting journaling (choice B) may be helpful interventions but assessing for suicidal ideation takes precedence due to the immediate risk of harm. Providing positive affirmations (choice D) is not the priority when safety is a concern.

3. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the LPN/LVN take?

• A. Notify the healthcare provider immediately and prepare for administration of an antidote.
• B. Notify the healthcare provider of the symptoms prior to the next administration of the drug.
• C. Record the symptoms as normal side effects and continue administration of the prescribed dosage.
• D. Hold the medication and refuse to administer additional amounts of the drug.

Correct answer: B

Rationale: When a client being treated with lithium carbonate for bipolar disorder develops symptoms like diarrhea, vomiting, and drowsiness, it could indicate lithium toxicity. The appropriate action for the LPN/LVN is to notify the healthcare provider immediately of these symptoms before the next administration of the drug. This prompt communication is crucial to ensure that the healthcare provider can assess the situation, adjust the treatment plan if necessary, and prevent potential complications associated with lithium toxicity. Option A is incorrect because administering an antidote should be based on the healthcare provider's assessment. Option C is incorrect as these symptoms are not normal side effects and could indicate a serious issue. Option D is incorrect because refusing to administer the drug without consulting the healthcare provider could delay necessary interventions.

4. A LPN/LVN is preparing to care for a dying client, and several family members are at the client's bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select one that does not apply.

• A. Discourage reminiscing
• B. Make decisions for the family
• C. Encourage expression of feelings, concerns, and fears
• D. Explain everything that is happening to all family members

Correct answer: B

Rationale: Encouraging the expression of feelings, concerns, and fears is a therapeutic technique that helps the family cope with the situation and express their emotions. This approach fosters trust and emotional release. Making decisions for the family is not appropriate because it takes away their autonomy and control during a difficult time. Discouraging reminiscing may hinder the family's coping mechanisms by discouraging them from sharing memories and finding comfort in the past. Explaining everything that is happening to all family members promotes transparency and understanding, which can help reduce anxiety and fear.

5. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?

• A. Encourage the client's self-motivation by asking her to assist with other activities.
• B. Provide an alternative suggestion for the client to participate in the unit's activities.
• C. Allow the client to serve dinner trays to other clients but monitor closely for any signs of distress.
• D. Explain to the client that she needs to focus on her own recovery and cannot participate in serving dinner trays.

Correct answer: B

Rationale: Clients with anorexia should not be allowed to plan or prepare food for unit activities, as this can reinforce their perception of self-control. Allowing the client to serve dinner trays (C) may trigger distress or unhealthy behaviors. Therefore, it is best to provide an alternative suggestion for the client to participate in the unit's activities (B). Encouraging the client to assist with other activities (A) may inadvertently reinforce negative behaviors related to food. Explaining to the client that she cannot participate in serving dinner trays (D) without offering an alternative does not address the client's desire to help and may lead to feelings of rejection.

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